Put Cigarettes in a Brown Paper Wrapper?

Getting rid of branded cigarette packaging might make quitting easier for smokers, an Australian study suggested.

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Beginning in September 2012, tobacco products sold in Australia were required to be packaged in plain, dark brown packs with 75% of the front of the pack occupied by graphic health warnings.

Compared with smokers smoking from branded packs, smokers who were smoking from the new plain packs were more likely to think about quitting and to rate quitting as a higher priority in their lives.

Getting rid of branded cigarette packaging might make quitting easier for smokers, an Australian study suggested.

After Australia implemented plain, brown packaging to emphasize health warning labels, the likelihood of thinking about quitting at least once a day in the prior week rose 81%, adjusted for prior attempts and other factors (P=0.013), Melanie Wakefield, PhD, of Cancer Council Victoria, Australia, and colleagues found.

Smokers also reported quitting as a higher priority in their life, with a nonsignificant trend for perceiving their cigarettes as less satisfying than before the change in packaging, the group reported online in BMJ Open.

These findings from the first months that the policy went into effect are important, according to the researchers, "since frequency of thoughts about quitting has strong predictive validity in prospective studies for actually making a quit attempt."

They suggested that the initial effects appear to fit with the aims of the policy.

Australia became the first and only country to move to plain packages in September 2012, when it required all cigarettes sold in Australia to be in plain, dark brown packs, with 75% of the front covered with graphic health warnings and the brand name and cigarette type in a standardized font.

Before that, the pictures with warnings of lung cancer, pregnancy-related harm, and other risks covered 30% of the front of packs in that country.

Plain packs haven't yet been proven to cut smoking rates, but the results do shore up the evidence for a real-world impact on smokers' perceptions, which had only previously been studied in experimental settings, as Wakefield's group noted.

They analyzed the annual population-based Victorian Smoking and Health Survey, which included telephone interviews of adults from November through December 2012, encompassing the period when the new plain packs started to be available at retail outlets through when they were the only packs allowed to be sold.

Of the 536 current smokers in the analysis, 72% had a plain pack when surveyed. That proportion increased over time during the study period from 57% to 85% by the final week.

66% higher odds of perceiving cigarettes to be of lower quality than a year ago among plain-pack versus branded-pack smokers (P=0.045)

A higher rating for quitting smoking as a priority, with a mean of 6.76 among plain-pack smokers versus 5.62 among those smoking from branded packs (P<0.001)

51% higher odds of approving of plain packaging among those smoking from such packs versus branded packs (P=0.049)

The group was also 70% more likely to report their cigarettes as less satisfying than before the change in packaging, although this was not a significant difference (P=0.052).

Likewise, plain-pack smokers thought "often" or "very often" about the harms of smoking in the prior week 43% more, but without statistical difference, compared with other smokers (P=0.115).

Nor were there significant differences in intention to quit in the next 30 days or 6 months, in belief that the dangers of smoking had been exaggerated, or in support for the larger graphic warnings on packaging.

"Given that 73% of Australian smokers intend to quit and over 90% regret having started, smokers may acknowledge such packaging changes as a source of motivation or reminder for quitting," Wakefield's group suggested as a reason for their findings.

However, residual confounding may also have been a factor, given that the plain-pack smokers were 2.6-fold more likely to have tried quitting previously than those still smoking from a branded pack, the researchers acknowledged.

"Avoidance of plain packs by these smokers would be entirely consistent with the notion that plain packs make smokers feel uncomfortable about their smoking, as found in two naturalistic studies," they wrote. "However, even if this is the case, the net effect of plain packaging for quitting remains positive."

The group also cautioned that the study couldn't attribute the results to the plain, logo-free packaging alone, because the size of the pictures depicting health hazards of smoking increased at the same time.

Further research is needed to determine the longer-term impact of the policy change and any effect on youth smoking, they added.

The study was funded by Quit Victoria.

Wakefield reported having no conflicts of interest to disclose, though two co-authors received financial support from Quit Victoria.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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